HealthCare.gov Shows Government IT Procurement Needs Reform

Former ONC chief David Blumenthal says a disconnect between the contracting office and IT managers increases the risk that government tech projects like HealthCare.gov will fail.

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The flawed government contracting process for complex health IT projects -- dramatized by HealthCare.gov -- seriously needs to be reformed, said David Blumenthal, MD, president of the Commonwealth Fund and former national coordinator of health IT. Blumenthal laid out his views in a post on The Health Care Blog (THCB) and an interview with InformationWeek Healthcare.

Obamacare's originator agrees with Blumenthal. President Obama recently promised to take a close look at the IT procurement process after the troubled federal marketplace for health insurance is fixed.

In his THCB article, Blumenthal contrasted the procurement process that the Office of the National Coordinator for Health IT (ONC) used when he worked there with the process that Partners Healthcare in Boston used to select an electronic health record (EHR) vendor when he was chief health information and innovation officer at Partners.

The key difference was that, whereas Partners' executives and clinicians were closely involved in the EHR selection process, ONC officials had little input into the RFPs or the contracting decisions made by the Department of Health and Human Services (HHS). Partners' physicians, technologists, and administrators met with representatives of the competing vendors, saw demonstrations of their products, and thoroughly evaluated the companies' capabilities and financial plans. ONC, in contrast, depended wholly on the contracting office to pick the best vendors.

"Officials extensively trained in the details of federal procurement, but lacking familiarity with our programs or field of work, would put the RFP out to bid," wrote Blumenthal.

An expert panel -- over which we had minimal control -- would evaluate the responses. Months later, the contracting office would present us with the signed contract.

The winner was usually picked from a group of companies with considerable experience working the federal procurement process. If we weren't happy with the firm, or with their later performance, there was virtually nothing we could do about it. Getting out of this shotgun marriage meant months of litigation, during which the funds would be frozen and the work itself would grind to a halt.

If the HHS contracting office was too busy to take on an ONC assignment, Blumenthal told InformationWeek Healthcare, his office would sometimes have to go to another federal department, such as Interior, Education, or Housing and Urban Development, to put a contract out to bid. ONC sometimes had to do this to meet the very aggressive deadlines imposed on it by the HITECH Act, he noted. Obviously, people in these other departments had little or no familiarity with health IT.

David Blumenthal, MD.

In contrast, the HHS contracting office included some people with knowledge of the health IT field, Blumenthal said. "But they'd never have the depth of knowledge or the investment or the time to do the kind of careful procurement that is needed in a brand new, highly innovative, incredibly challenging space like the website rollout or some other [IT] work that needs to be done in the federal government," he said. "In the end, there's no substitute for the consumer and the provider of service meeting, talking, and vetting one another and generating trust."

While ONC made suggestions about who to include in the expert panels that advised the contracting office, Blumenthal said, the health IT office couldn't choose the experts. And it had no way to brief them. "We didn't have a chance to tell them what our priorities were and what our critical choice factors were. In the end, they were not the consumers of the product, and they couldn't know our priorities."

Blumenthal noted in his article that this system arose because the public didn't trust government officials enough to let them meet with potential contractors. So why do the best-connected firms tend to get the contracts? "I'm not an expert on the procurement process," he told InformationWeek Healthcare. "But if you're at this long enough, there are clearly ways to work the process and increase your chances of success, even if you can't control those chances directly."

Blumenthal said he didn't know whether the federal procurement process prevented CMS from hiring a prime contractor to supervise the several dozen firms that worked on HealthCare.gov. But he added, "I think there's a general recognition right now that a prime contractor with experience in supervising large, complicated IT projects is valuable. That capability doesn't seem to have been there during this process."

The former ONC chief said he didn't know enough about conditions on the ground to give those trying to fix HealthCare.gov any specific advice. But he does have a recommendation on how to fix the IT procurement process.

"I think there needs to be a supervised and careful opportunity for people familiar with the content of programs to interact directly with the potential vendors. You need to break down the barriers between the users and providers of services, at least in the area of IT -- and maybe just for certain kinds of IT projects, but not other kinds. For example, I don't think that's necessary if you're buying desktop computers in bulk. But for creating a complicated, new kind of software capability, knowing who you're working with is absolutely vital."

Moving email to the cloud has lowered IT costs and improved efficiency. Find out what federal agencies can learn from early adopters. Also in the The Great Email Migration issue of InformationWeek Government: Lessons from a successful government data site. (Free registration required.)

Every big tech vendor and integrator going has set up shop in the D.C. area to "work the system," as this article puts it. In fact, Reston, VA, is a mini Silicon Valley that thrives on govenment tech contracts. I don't see it as a problem that there is a procurement process, procurement professionals or even vendors that are familiar with all of that. But if the process and the decisions are separated from the requirements and the people who have to make the system work -- as this story suggests -- that's a problem. There has to be accountability for decisions. That seems to be what's lacking here.

One of the best quotes I've read about what went wrong with healthcare.gov was from Elaine Kamarck, a former adviser to Al Gore who worked on the "reinventing government" project in the Clinton administration. Kamarck told Politico that the real lesson of the rollout, is that DHHS broke every rule for managing a big technological project: Specifically:

Give give one person the power and responsibility to supervise the entire project;

Build and test the technology repeatedly, since everyone knows websites crash; and

Create an environment where people feel free to give the boss bad news.

How many IT projects have you worked on that broke one of those rules, recently?